WORKSAFE VCFL SPECIAL CONSIDERATION - FAMILY PERMIT

(For Permits applications prior to June 30th in each year)

PLAYER TO COMPLETE

First Name:

Surname:

Gender:

Date of Birth:

Street Address (Permanent residential address):

Suburb:

Post Code:

Home Phone:

Mobile:

Fax:

E-mail:

Street Address (Residential address while on Permit):

Suburb:

Post Code:

Home Phone:

Mobile:

Fax:

E-mail:

Current Registered Club:

League:

Apply for Permit to Club:

League:

Players Current Club to Complete:

The ___________________ Football Club Grants/Refuses the permit.

Date: _____________ Signature: ______________________

Players Current League to Complete:

The ___________________ Football League Grants/Refuses the permit.

Date: _____________ Signature: ______________________

Players Permit Club to Complete:

The ___________________ Football Club Grants/Refuses the permit.

Date: _____________ Signature: ______________________

Players Permit League to Complete.

The ___________________ Football League Grants Refuses the permit.

Date: _____________ Signature: ______________________

Please continue to page 2.

AREA MANAGER/S TO COMPLETE.

I being the Area Manager for the _________________________________________________ and am satisfied the player has met the criteria outlined in the Special Consideration – Family Permit Grants/Refuses the Permit for the above named player.

Date: _____________ Signature: ______________________

I being the Area Manager for the _________________________________________________ and am satisfied the player has met the criteria outlined in the Special Consideration – Family Permit Grants/Refuses the Permit for the above named player.

Date: _____________ Signature: ______________________

The original copy of the permit shall be retained by the Area Manager Special Consideration - Family Permit Where a player under the age of 16 years as of the 1st of January is in a situation where the parents have separated and have special custody arrangements such players may be eligible to apply for a permit to play at a second or alternate club which is more than 150km away from his / her original club. A player eligible under this permit may only participate in one game per weekend and may be eligible for finals providing they have qualified under the local provisions however they may only play in one finals series per weekend. Permits will not be granted where a local Area Agreement can be applied. The ultimate verification and approval of this special Family Permit will rest with the Area Manager after lodgement of the Family Permit Form and proof of separation and residence of both parents. Family Permit cannot be applied for or approved after June 30th in each year and in only applicable for that year.